Welcome to Lesson 4 of 4 of this learning activity titled Mastering Performance Composite Measures. The content in this lesson was developed by Shelley Conine. I am Kate Malish and I will be narrating this lesson. The objectives for Lesson 4 of 4 NCDR Overview of Mastering Performance Measures include learn how to apply a systematic approach in identifying areas of process improvement as well as tangible evidence of excellent care provided. The Chest Pain MI Registry offers six distinct views of a hospital performance to provide practitioners and institutions that deliver cardiovascular services with tools to measure the quality of care provided and identify opportunities for improvement. Metric 1 Overall AMI Performance Composite is an overview of performance of the overall care provided for pre-arrival STEMI and NSTEMI patient populations. Metric 2 Overall Defect-Free Care Composite is comprised of the same individual performance measures as Metric 1 Overall AMI Care. However, the measurement methodology is an all-or-nothing measurement methodology to provide a different distinguished view. Metric 3 The STEMI Performance Composite is a concise view of pre-arrival STEMI care. Metric 4 The NSTEMI Performance is specific to the care provided to the NSTEMI patient. Metric 5 The Acute AMI Performance Composite focuses on the care provided in the acute phase of a myocardial infarction. Metric 6 The Discharge AMI Performance Composite denotes AMI care provided at discharge. The dashboard is a streamlined, centralized location for assessing hospital metric performance. The eReports dashboard provides an at-a-glance view of the executive summary metric performance in comparison to the U.S. Registry benchmark distribution. This is provided in a graph format for both individual performance and the performance composite measures. Also provided is an interactive 3-year trending graph providing insights into metric performance over time. Additional features of the eReports dashboard is the patient-level detail report to evaluate the individual patient and or procedure details and includes the metric numerator and denominator. The data can be filtered to better understand patient and or procedure characteristics and physician treatment patterns. Submitting early and often provides the most up-to-date metric performance. The data is updated in near real-time with weekly data aggregation. In this patient-level detail report of metric 1, Overall AMI Care Performance, all eight patients in this sample have one or more eligible individual care measures, as indicated with yes in the composite numerator. There are 53 eligible individual performance measures met and 8 eligible individual performance measures not met. The numerator is 53, the count of all the yeses, and the denominator is 60, the count of all the nos and yeses, for a score of 88%. Compare to the U.S. hospital rolling four-quarter performance distribution of the 50th percentile score of 92.6%. This sample demonstrates less than the 50th percentile of 92.6 with a score of 88% as demonstrated by the dark blue bar. The goal is to have a score at or above the 50th percentile. Let's see how this sample measures with the other distinct views of the performance composite measures. In this patient-level detail report of metric 2, Overall Defect-Free Care Performance Composite, there are eight eligible individual patients with five patients receiving perfect care. This is indicated by a yes in the composite numerator. There are three patients that did not receive perfect care, as indicated a no in the composite numerator. The numerator is 5, the count of all the yeses in the composite numerator, and the denominator is 8, the count of all the yeses and nos in the composite numerator, for a score of 66%. Compare to the U.S. hospital rolling four-quarter performance distribution of the 50th percentile of 61.4%. This sample demonstrates more than the 50th percentile of 61.4 with a score of 66% as demonstrated by the dark blue bar. The goal of having performance better than the 50th percentile is met. Let's continue to see how this sample measures with the other distinct views of the performance composite measures. In this patient-level detail report of metric 3, STEMI Performance Composite, there are 27 eligible individual performance measures with all 27 met, indicating all eligible individual performance measures were provided with a score of 100%. Compare to the U.S. hospital rolling four-quarter performance distribution, the 50th percentile is 95.5%. This sample demonstrates performance is greater than the 90th percentile of 98.6% as demonstrated by the dark blue bar. Let's continue to look at the remaining three performance composites. In this patient-level detail report of metric 4, NSTEMI Performance Composite, there are 24 eligible individual performance measures met and 7 eligible individual performance measures not met. The numerator is 24, the count of all the yeses, and the denominator is 31, the count of all the nos and yeses for a score of 77%. Compare to the U.S. hospital rolling four-quarter performance distribution, the 50th percentile is 91.4%. This sample demonstrates less than the 10th percentile of 79.9, with a score of 77%, meaning greater than 92% of the U.S. hospitals are performing better, demonstrated by the dark blue line. The goal is to perform at or greater than the 50th percentile. There are two more distinct views to analyze with the remaining performance composites. In this patient-level detail report of metric 5, Acute AMI Performance Composite, there are 17 eligible individual performance measures, with all 17 met. All eligible individual performance measures were met with a perfect score of 100%. Compare to the U.S. hospital rolling four-quarter performance distribution, the 50th percentile is 95%. This sample demonstrates a score better than the 90th percentile score of 98, with a score of 100%, meaning the performance of this sample is in the top 2%, indicated by the dark blue bar. The goal of having performance better than the 50th percentile is met with a perfect score of 100%. In this patient-level detail report of metric 6, Discharge AMI Performance Composite, there are 33 eligible individual performance measures met and 7 eligible individual performance measures not met. The numerator is 33, the count of all the yeses, and the denominator is 40, the count of all the noes and yeses, for a score of 82.5%. Compare to the U.S. hospital rolling four-quarter performance distribution, the 50th percentile is 91.6%. This sample demonstrates less than the 50th percentile of 91.6, with a score of 82.5%. The goal is having a score at or greater the 50th percentile. This sample demonstrates a score below the 25th percentile of 82.5%. Let's look at the overall picture of how the sample compared to the U.S. National Benchmark and identify areas for process improvement. The blue bar represents the sample, the orange bar is the U.S. 90th percentile, the gray is the U.S. 50th percentile, and the yellow bar is the U.S. 25th percentile. Metric 1, Overall AMI Performance, demonstrates the sample performed at the 25th percentile. Metric 2, Overall Defect-Free Care, demonstrates the sample performed above 50th percentile, however, less than the 90th percentile. Metric 3, STEMI Performance, demonstrates the sample performed at 100% and exceeding 90th percentile, tangible evidence of excellent care provided. Metric 4, NSTEMI Performance, is performing significantly less than the 25th percentile. Metric 5, Acute MI Performance, demonstrates the sample performed at 100%, exceeding the 90th percentile, tangible evidence of excellent care provided. Metric 6, Discharge AMI Performance, demonstrates performance well below the 25th percentile. When analyzing the STEMI Performance, or Care and Acute AMI Performance, are performing well with no room for improvement currently. The NSTEMI Performance composite and the Discharge AMI Performance composite are performing less than the 25th percentile, indicating the NSTEMI patient population is not receiving eligible discharge measures consistently. Once internal process improvements are initiated and successful for the NSTEMI discharge measures, the score for the Overall AMI Care and Overall Defect-Free Care will also greatly improve. The Chest Pain MI Registry Performance composites provide six distinct detailed analysis of a hospital's individual performance in relation to the entire registry population. Giving insight to care variations, quality improvement opportunities, and tangible evidence of successful process improvement initiatives, the report provides the opportunity to compare hospital practice patterns to NCDR benchmarks. This concludes Lesson 4 of 4, Mastering Performance Composite Measures. Thank you for your participation. For more information, please visit www.ncdr.gov.

Mastering Performance Composite Measures

NCDR Overview

hospital performance

Chest Pain MI Registry

quality of care